Get Mran Form

The Mran Form is essential for submitting crossover inpatient claims to the appropriate authorities. This guide provides clear, step-by-step instructions on how to accurately complete this form online, ensuring all necessary information is included.

Follow the steps to effectively complete the Mran Form.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Enter the Medicare paid date as indicated on the Medicare Remittance Advice (RA) or Remittance Notice (RN).
3. Fill in the billing provider's name in the designated field.
4. Input the National Provider Identifier (NPI), Atypical Provider Identifier (API), or Texas Provider Identifier (TPI) as applicable.
5. Provide the billing provider's street address, followed by their city, state, and ZIP code.
6. Indicate the Medicare bill type as stated on the RA or RN.
7. Specify the first date of service (DOS) for all procedures in MM/DD/YYYY format.
8. Enter the last DOS for all procedures in MM/DD/YYYY format.
9. Input the patient's last name as per the Medicare or MAP RA/RN.
10. Fill in the patient's first name as shown on the RA or RN.
11. Provide the Medicare Health Insurance Claim (HIC) number, ensuring no other ID numbers are used.
12. Enter the Medicare Internal Control Number (ICN) that is included on the Medicare or MAP RA/RN.
13. Document the total charges billed as mentioned on the RA or RN.
14. Specify the covered charges as indicated in the Medicare or MAP documentation.
15. Document the non-covered charges along with the corresponding reason code from the Medicare RA/RN.
16. Input the diagnosis-related group (DRG) amount if applicable for inpatient claims.
17. Provide the Medicare deductible amount as specified on the RA or RN.
18. Document the blood deductible amount for inpatient claims, if necessary.
19. Enter the Medicare coinsurance amount as stated in the RA or RN.
20. Input the Medicare paid amount as indicated in the documentation.
21. Enter the DRG code if applicable for inpatient claims.
22. After completing all fields, proceed to save changes, download, print, or share the form as needed.

Complete your documents online with confidence and ensure accurate submission.